Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Health Care Orginizations > Reimbursement > Flashcards

Reimbursement Flashcards

1
Q

3 Traditional Ways of Physician Reimbursement

A
  1. FFS
  2. Capitation
  3. Salary
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Fee-for-service

A

Reimbursement for each unit of medical service provided

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Capitation

A

Physician gets PMPM, from government / insurer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Salary

A

Monthly lumpsum payment from insurer, hospital, or government

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

FFS: Physician Pros

A
  1. Reflects work done
  2. Perceived as fair
  3. Clinical freedom
  4. Room to gain extra income
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

FFS: Physician Cons

A
  1. No secure income
  2. Heavy admin work
  3. Delayed / slow payment
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

FFS: Patient Pros

A
  1. Incentive to provide high quality care
  2. No cream skimming
  3. Physician choice
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

FFS: Patient Cons

A
  1. Copays
  2. No incentive for preventative care
  3. Access tied to your finance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

FFS: Insurer Pros

A
  1. Physician productivity

2. No discrimination based on patient health

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

FFS: Insurer Cons

A
  1. Overtreatment

2. No cost containment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Capitation: Physician Pros

A
  1. Steady income stream
  2. Low administrative cost
  3. Rapid payments
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Capitation: Physician Cons

A
  1. Does not reflect work done
  2. Perceived as unfair
  3. No clinical freedom / extra income
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Capitation: Patient Pros

A
  1. Incentive to cost contain
  2. Incentive for preventative care
  3. No copays
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Capitation: Patient Cons

A
  1. Incentive for cream skimming
  2. Fixed reimbursement promotes short visits
  3. No free physician choice
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Capitation: Insurer Pros

A

Cost containment

Same pros are patients

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Capitation: Insurer Cons

A

Undertreatment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Salary: Physician Pros

A
  1. Steady income stream
  2. Low administrative cost
  3. No disputes about pay
18
Q

Salary: Physician Cons

A
  1. No extra income
  2. Limited working hours
  3. No clear measure of “fair”
19
Q

Salary: Patient Pros

A
  1. Incentive to cost contain
  2. Incentive for preventative care
  3. No copays
20
Q

Salary: Patient Cons

A
  1. No incentive for innovative / high-quality care

2. Potential for unproductive doctors

21
Q

Salary: Insurer Pros

A
  1. Incentive to cost contain
  2. Incentive for preventative care
  3. No copays
22
Q

Salary: Insurer Cons

A

Unproductive physicians

23
Q

Indemnity Plan

A

Free choice of hospitals / physicians

No insurer employed hospitals / physicians

No subsidized treatment

24
Q

IDN

A

Integrated delivery network

Managed care organization

Integrate financing / insurance with delivery and payment

25
Q

Reasons Managed Care Fails

A
  1. too many restrictions
  2. increased bargaining power through hospital consolidation
  3. MCOs use expensive tech
26
Q

Factors Leading to Lower Supply and Utilization

A
  1. Reimbursement changes
  2. Rural hospital closure
  3. Impact of managed care
27
Q

Reimbursement changes

A

Retrospective reimbursement based on total costs

28
Q

Cost-plus reimbursement

A

Per diem, you make more for higher LOS (retrospective)

Rates are based on total cost (including capital costs)

29
Q

DRG (what)*

A

Diagnosis related group - 1982 introduced by CMS

Group similar clinical diagnosis in same clinical categories

Diagnosis and reimbursement based on case rate (prospective reimbursement)

Part of Tax Equity and Fiscal Responsibility Act

30
Q

DRG (why)*

A

DRGs standardize costs and give incentive to improve efficiency because payment depends on diagnosis, payment is independent of LOS

31
Q

DRG (how)*

A

Government determines average cost to treat Medicare patient in each of the 750 DRGs

DRG determined by principle diagnosis and up to 8 secondary, adjusted for geography

32
Q

ICD 10 Codes

A

Billing code that ID the diseases, international classification of diseases

33
Q

Consequences of DRG

A
  1. Encourages cherry picking
  2. Encourages upcoding, to get more severe diagnosis
  3. Can encourage more intensive treatment
34
Q

Mitigating Negative DRG Incentives

A
  1. Hospital Competition
  2. Quality Improvement Initiatives
  3. Internal Ethics Committees
  4. External Peer Review
  5. PAC services
35
Q

DRG reimbursement: Medicare

A

DRG reimbursement for acute inpatient

36
Q

DRG reimbursement: Medicaid

A

Some states do adjusted DRG based on Medicare, or per diem / FFS reimbursment

37
Q

DRG Incentivizes

A
  1. Early discharge
  2. Shift to alternative services
  3. Efficiency / cost-containment
38
Q

DRG reimbursement: Commercial

A

Offers adjusted DRG amounts

Also offers per-diem / FFS rates that are below the charge master (discount)

39
Q

DRG reimbursement: Uninsured

A

Pay the highest prices (charge master rate)

40
Q

Cost-plus incentives

A
  1. Increase LOS

2. No motivation to contain costs

41
Q

Reimbursement maximizing pop health

A

Reimbursement based on outcomes / cost effectiveness

Health Care Orginizations (8 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions